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Under siege and grappling with joblessness, factional violence and the aftermath of war, Gazans are turning to pills as they seek to escape reality. Donald Macintyre speaks to a mental health group struggling to help addicts.

Abu Ahmed lived through last winter's Gaza war in a daze. Though the district where he lives was invaded by Israeli ground forces and came under heavy fire, including the use of white phosphorus shells, he felt little fear. For by then, the 45-year-old unemployed father of 10 was popping tablets of the painkiller Tramadol to feed an ever more dangerous habit. "Of course you care about the children but [with the drugs] you forget about yourself," he explains. "You feel less frightened."

Manufacturers warn the maximum daily dose of the synthetic opioid should be no more 300mg per day; Abu Ahmed was taking as much as 800mg – in the grip of an addiction which has rapidly spread throughout Gaza over the last two years. As the population struggles to cope with Israel closing their home to the outside world, the sometimes violent power struggles between Fatah and Hamas, and then the aftermath of Operation Cast Lead, the Tramadol pills – smuggled in through tunnels from Egypt – have provided a welcome escape from reality.

Mental health professionals say there has been a rise in the drug's usage in Gaza since the war. The Hamas authorities have tried to crack down on it, but the drug's severe withdrawal symptoms means it is a seriously hard habit to break. Hasan Shaban Zeyada, a senior psychologist at the Gaza Community Mental Health Programme (GCMHP) is convinced that many of the psychological problems underlying the addiction are "the consequence of living in this situation: the siege, internal division and the war".

Abu Ahmed used to have a good job as a driver. But like an estimated 100,000 other Gazans he lost it when Israel imposed its blockade after Hamas seized control of the strip from Fatah in June 2007. "Before the war the situation was so hard. There was no work, plus I had to take care of 11 people, including my wife. All people could do was sit around in the street and drink tea or coffee."

Depressed and suffering from headaches, he was offered a Tramadol pill by one of his friends. Several of them were using the drug for its supposed power to improve sexual performance, but for Abu Ahmed it was just a way of relieving the strain of life. "When I took it, I felt very relaxed," he says.

But Abu Ahmed soon became hooked. Supplies of Tramadol had surged after Hamas militants blew a breach in the southern wall between Gaza and Egypt in January 2008. "You could get it at pharmacies and there were people selling it on the street," he says. He quickly graduated from taking one pill a day, to three or four and then, though he could ill afford it, as many as eight.

A combination of a doubling in price to around £3.40 for a strip of 10 tablets and a Hamas edict (belated and far from effective) that pharmacies should not sell the drug without a prescription persuaded Abu Ahmed that he had to stop. "I tried to get away from it but I couldn't. I had a headache, pain in every part of my body. I had to go the bathroom every 10 minutes. I was sweating. Then you take one pill and you feel better of course."

It was about six weeks after that that Abu Ahmed– who has a history of drug abuse with hashish – turned, on the advice of a friend, to the GCMHP, the pioneering Palestinian organisation started in 1990 and still directed by the territory's leading psychiatrist and civil society spokesman Dr Eyad Sarraj. With the help of counselling from the group's trained therapists, as well as controlled and decreasing doses of alternative drugs like Avitan, he has stopped taking Tramadol. At the height of his addiction, Abu Ahmed was going without eating for up to three days and his weight dropped to 58 kilos (just over nine stone). Now it is back up to 85.

"They [the GCMHP] made me feel I was in safe hands," explains a grateful Abu Ahmed, adding that the agency arranged for food aid for his family while he was recovering. "They showed respect. And they came to my house to tell my family how they should cope with me when I became nervous and angry."

Yet for all its high professional standards, the organisation cannot help more than a minority of addicts. Although some unofficial estimates put the number of drug addicts as high as many thousands, the GCMHP's Mr Zeyada, who trained in Tel Aviv University, will not, as a scientist, hazard a figure. But he says there is a shortage of mental health provision in Gaza and that "GCMHP cannot take responsibility for the whole community".

Although there has been improvement in mental health awareness in the territory, many residents in socially conservative Gaza baulk at the idea of seeking treatment for psychological problems. "The level of stigma is so high," he explains. Instead, many patients go to their GPs reporting physical problems like headaches, back or abdominal pain, and the doctors, "because of a lack of knowledge about psychological disorder," simply prescribe analgesic drugs – of which Tramadol is a prime example – and "after a while the patients become addicts or abusers".

Operation Cast Lead has been over for nine months, but the return to a state of siege, with unemployment at a record 45 per cent, has left a sense of "helplessness and powerlessness" among residents, compounded by the fact that there is no guarantee the war will not be repeated.

For women, the sense that they exist only to serve their children and husbands makes them especially vulnerable to depression – and use of medication like valium and xanax. For men, the feelings of powerlessness and loss of masculinity are all too often caused by an inability to protect their children in war or provide for them in relative peace. "For a father who cannot fulfil the basic needs of his children it is not easy, especially in a society like Palestinian society," says Mr Zeyada.

Many young people, he adds, are also vulnerable. "They don't have hope, they cannot do anything for the future. They are disappointed, depressed, helpless and powerless. They can't find a job, they can't plan for the future, or [afford to] get married."

Until three weeks ago 21-year-old university student Mohammed, who had first taken the occasional Tramadol pill in 2006 after failing his high school exams, was on a daily dose of 1,000mg per day, increasingly alarming his family as he sat at his computer all night and slept all day. "You are in another world," he says. "Even when people keep criticising you, you don't feel angry."

In his first month of rehab, Mohammed explains that his addiction reached crisis point when his father, who used to work in Israel and is a passionate believer in university education for his children, was tipped off about his habit. There followed a climactic row last month in which his father threw him out of the family house in northern Gaza, telling him: "If you want to go back to study, and be committed to Islam, then I will help you get out of this problem. If you don't want to be helped, then I will take you to the [Hamas] police and that's it."

Mr Zeyada says another factor is the deep split between Fatah and Hamas, which there appears, once again, little hope of healing. Not only does it divide individual families, but for many Gazans it compromises their proud Palestinian national identity with a divisive factional one which makes them especially sensitive to criticism and hostility from political opponents. There are even cases from school playgrounds of conflict breaking out between children favouring (for non-political reasons) a particular colour T-shirt: yellow (Fatah) or green (Hamas).

Abu Ahmed agrees: "Even in one home you have Fatah and Hamas. That is a big problem." But now that he feels much better, he looks back on the depression that he believes turned him to Tramadol. "Look," he says. "Even if a person kills someone, he can still sleep at night. If he goes out and steals something, he will still sleep. But if you have children and you can't find work to give them what they need, then you can't sleep."

* Tramadol is a powerful painkiller with a narcotic effect. A single 200 mg dose can leave users sedated for much of the day so time passes quickly.
* One user described it as like being wrapped in a "full body blanket" where problems are not solved but the "volume is turned down a notch".
* It has similar effects to opiate painkillers such as pethidine inducing sleepiness, a lack of inhibition and a sense of wellbeing.
* Because it is not an opiate, it is not controlled as closely and may be easier to obtain.
* Tolerance builds quickly and users need increasing doses to obtain the same effect. Heavy users report forgetting chunks of the day.

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Gazans turn to painkillers to numb the pain of warAbu Atallah got addicted to painkillers after his house was destroyed and his 12-year-old daughter was killed in Israel's bombardment of the Gaza Strip at the turn of the year.

"I'm not an addict," said the 39-year-old father of five, who now lives in a cramped rented apartment in Gaza City, his home still in ruins.

"The problem is that I cannot sleep unless I take one or two pills to calm me down."

Gazans are increasingly turning to Tramadol, a painkiller known locally by its brand name "Tramal," to ease the pain of a crippling two-year Israeli blockade and the lingering devastation from last winter's war.

Abu Abdullah started taking Tramadol to deal with the stress of chronic unemployment.

"I haven't worked in three years and I can't meet the needs of my children," the 45-year-old labourer said, asking that his real name not be published.
"In the beginning, I took one Tramal I got from friends and I felt much better. Soon I was taking five pills a day."

Drug use was once rare in Gaza's conservative society, but addiction experts say prescription painkillers and marijuana have become more common since Israel and Egypt sealed off the territory to all but basic goods in the wake of the Islamist Hamas movement's bloody takeover in June 2007.

The blockade has confined nearly all of Gaza's 1.5 million people to the narrow coastal strip where the economy is on the verge of collapse and most residents survive on foreign aid.

Hard drugs are virtually non-existent in Gaza but many people have turned to prescription painkillers in the wake of the devastating 22-day war that Israel launched on the territory on December 27, 2008, according to experts.
"Some youths come in every day to buy painkillers such as Tradamol, but we don't sell it if they don't have a prescription," said a Gaza pharmacist, who declined to be named.

He added, however, that many people turn to the black market for their fix.
"The situation of always being on the lookout for the next Israeli war puts the people of Gaza in a state of worry and perpetual tension, in addition to the unemployment and the poverty," said Samir Zaqut, a psychiatric researcher in Gaza.

The Islamist government ruling Gaza strictly forbids the use or sale of drugs such as Tramadol without prescriptions, and last week police displayed 22kg of hashish and around 4,000 pills, mostly Tramadol, which they said they had seized in a raid.

"We are fighting against the drug trade without mercy and we have been able to completely eliminate the trade and use of cocaine," said Sami Yaghi, the Hamas-run government's anti-drug tsar.

"The biggest obstacle is the lack of control over the crossings, which the Israeli enemy exploits to allow whatever it wants to enter," he added.

He admitted, however, that the drugs are also coming in through the massive tunnel network beneath the Gaza-Egypt border, a lifeline for the local economy that is patrolled, regulated and taxed by Hamas authorities.

Abu Abdullah said the government's actions have made a difference, driving up the black market price to five times that of the pharmacies.

"It didn't used to be forbidden but now it is, so I'm trying to quit," he said.
But for him and many others, the addiction may prove too strong.

Doctors at a local rehabilitation centre recalled a young man who recently checked in with kidney failure after taking 20 Tramal pills in a single day.

The patient had two pills left in his pocket and asked the doctors to "give them to someone who needs them," according to one of the doctors, who asked not to be named. "This kid needs help," he said.